The how and the what of mandatory training

Nathanson et al. make a case for “career-long mandatory training” for rare but potentially fatal anaesthetic events and that this should be implemented and funded as a matter of urgency [1]. Despite having less than half the reported combined clinical years of anaesthesia experience of the sagacious authors, we echo their sentiment, with a particular focus on mandatory training for airway emergencies. The 7th National Audit Project (NAP7) demonstrated that airway complications occur commonly and ‘airway failure’ was reported to account for 30% of airway complications in cases surveyed [2]. Notably, such complications resulted in a significant number of cardiac arrests, deaths and adverse outcomes [2].

A recent Health Services Safety Investigations Body report described the tragic case of a 12-year-old boy with an anticipated difficult airway who died due to failed airway management, including multiple attempts at videolaryngoscopy and an emergency front-of-neck airway [3]. The report made several recommendations, including that the Royal College of Anaesthetists (RCoA) and other key stakeholders, provide guidance on requirements to update airway skills regularly, but did not propose how this could be mandated.

Therefore, we wish to consider two key areas: how mandatory training could be mandated; and what training is required, recognising potential benefits and challenges (Table 1). As Nathanson et al. highlight, the pathway or organisation with the authority to mandate training is opaque. In the UK, the General Medical Council may be best placed to do so [1], but the time required and the practicalities of delivery could be limiting factors. The RCoA could consider recommending training within its Guidelines for the Provision of Anaesthetic Services, but these would simply be guidelines rather than mandatory. A multi-organisation scoping exercise led by the RCoA is currently ongoing and may be a proactive step forward. However, until formalised mandatory training by a responsible authority is implemented widely, a bottom-up approach may be necessary. This could include evidence of airway training for annual sign-off or revalidation, as well as leadership for implementing this from the Airway Leads Network. Clinical Leads and Directors should embrace and enforce regular training in their departments and ensure dedicated time and resources to support delivery. Importantly, this will require clinicians themselves to take ownership of their training and actively seek opportunities for continuing development.

We believe that mandatory training should extend to technical skills training in frequently used airway equipment, such as videolaryngoscopes – particularly those used in the clinician's usual place of work – as well as procedures, such as awake tracheal intubation, to maintain proficiency. Worryingly, NAP7 found that a lack of familiarity with or misuse of airway equipment may have contributed to cardiac arrest in some cases, supporting the need for specific training. With ever-evolving devices and technology, we have an obligation to keep pace and familiarise ourselves with the tools of our trade through regular training and competency assessment. While we are under no illusions that mandatory training has challenges, the benefits should far outweigh them (Table 1).

Nathanson et al. give more than just sage advice, and we stand firmly behind their call to action [1]. As anaesthetists, expertise in airway management should be both guaranteed and maintained. Mandating regular training may be the way to achieve this. This will require a change in the status quo and concerted efforts from relevant stakeholders, starting with clinicians themselves, to ensure the necessary resources, infrastructure and support systems are in place to achieve this. Nathanson et al. quoted Oscar Wilde, who also suggested, “Experience is simply the name we give our mistakes.” We believe that experience should be the name we give for training to avoid mistakes.